Gastroenterology Coding Alert
Depth and Method Matters For Anorectal Biopsy
Question: How should I report an anorectal biopsy?
Louisiana Subscriber
Answer: First, you would consider the instrument your gastroenterologist used to obtain the biopsy. For instance, if the gastroenterologist used an anoscope to obtain a surface biopsy, you would report 46606 (Anoscopy; with biopsy, single or multiple). If she used a proctosigmoidoscope, then use 45305 (Proctosigmoidoscopy, rigid; with biopsy, single or multiple).
It's also likely that your gastroenterologist would perform an anorectal biopsy during a flexible sigmoidoscopy (45331, Sigmoidoscopy, flexible; with biopsy, single or multiple) or during a colonoscopy (45380, Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple).
Additionally, you should consider the biopsy's depth when anorectal biopsy. A surgical procedure for a deeper biopsy would call for coding 45100 (Biopsy of anorectal wall, anal approach [e.g., congenital megacolon]). This biopsy of the anorectal wall from an anal approach is also known as "suction biopsy." A pediatric gastroenterologist, for example, would perform 45100 to diagnose Hirschsprung's disease or congenital megacolon..
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